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NYS Comptroller

THOMAS P. DiNAPOLI

Taxpayers' Guide to State and Local Audits

Department of Health
Overpayments for Medicare Part C Coinsurance Charges (Follow-Up)


Issued: December 12, 2013
Link to full audit report 2013-F-26
Link to 30-day response

Purpose
To determine the extent of implementation of the one recommendation included in our initial audit report, Overpayments for Medicare Part C Coinsurance Charges (2011-S-33).

Background
Our initial report, issued on September 26, 2012, examined whether Medicaid made inappropriate payments to medical providers for services rendered to Medicaid recipients enrolled in a Healthfirst Medicare Advantage Plan. Many Medicaid recipients are also enrolled in Medicare Part C. Under Medicare Part C, managed care plans (also known as Medicare Advantage Plans) administer an individual's Medicare benefits. Medicare Advantage Plans have networks of participating providers that the plans reimburse directly for services provided to enrollees. Medicare Advantage Plan enrollees may be responsible for cost-sharing liabilities such as deductibles and coinsurance. However, these liabilities may be paid by Medicaid if the individual is also enrolled in Medicaid. When this occurs, plan providers bill Medicaid for enrollees' cost-sharing liabilities.

Our initial audit found Healthfirst misreported the cost-sharing liabilities of Medicaid recipients to some of its healthcare providers. As a result, 14 providers billed Medicaid for excessive amounts of coinsurance on 497 claims for clinic services. Because of the excessive claims, Medicaid made overpayments totaling $699,258 to the providers. At the time of the initial audit, Healthfirst took actions to prevent further errant claims and overpayments. Additionally, providers submitted claim adjustments for 126 of the 497 errant claims, resulting in Medicaid recoveries of $195,835. Our initial audit report contained one recommendation for the Department of Health to review and recover the remaining Medicaid overpayments for excessive Medicare Part C coinsurance.

Key Findings

  • The Department of Health implemented the recommendation to recover the remaining Medicaid overpayments identified in the initial audit. This resulted in the recovery of Medicaid overpayments totaling $500,115.

Key Recommendations

  • None

Other Related Audits/Reports of Interest

Department of Health: Overpayments to Cabrini Medical Center (2011-S-8)


State Government Accountability Contact Information:
Audit Director: Brian Mason
Phone: (518) 474-3271; Email: StateGovernmentAccountability@osc.state.ny.us
Address: Office of the State Comptroller; Division of State Government Accountability; 110 State Street, 11th Floor; Albany, NY 12236